The “diagnostic shadowing” framework: how adolescent anxiety may conceal ADHD-related executive dysfunction

Abstract

Background: ADHD and anxiety frequently co-occur during adolescence, yet ADHD recognition may rely on externally observable behaviors. Adolescents who compensate for executive-function difficulties through anxiety-driven effort may appear competent, directing clinical attention toward anxiety and delaying ADHD assessment.

Objective: To develop and justify a conceptual framework, termed **Diagnostic Shadowing**, explaining how anxiety-related coping and compensation may reduce the visibility of ADHD-related difficulties and influence clinical interpretation.

Methods: A structured conceptual synthesis was conducted using literature identified through PubMed/MEDLINE, APA PsycInfo, Scopus, Web of Science, and Google Scholar in September 2026. Evidence concerning ADHD, anxiety, comorbidity, executive functioning, attentional control, perfectionism, procrastination, compensation, and diagnostic recognition was integrated. Claims were classified as established evidence, inference, framework proposition, or hypothesis.

Results: The synthesis identified ADHD–anxiety co-occurrence, symptom overlap, informant and measurement limitations, executive dysfunction, altered inhibitory expression, and delayed ADHD recognition, particularly among females initially identified with anxiety or mood disorders. A seven-layer Diagnostic Shadowing framework was developed linking underlying vulnerabilities, environmental demands, compensatory responses, apparent competence, anxiety-focused interpretation, decompensation, and reassessment.

Conclusion: Diagnostic Shadowing is a heuristic framework rather than a diagnosis. It supports broader developmental assessment when executive difficulties persist in anxious adolescents while cautioning against overdiagnosis. Longitudinal, multi-informant research is needed to evaluate its clinical utility.